Psychotic depression — acute management and evidence (MEQ)

(i) Diagnosis and differentials. Working diagnosis: major depressive episode, severe, with psychotic features (mood-congruent guilt/persecutory delusions and accusatory auditory hallucination) — unipolar pending longitudinal bipolar exclusion. Differentials with discriminators: (1) bipolar depression with psychosis — prior hypo/mania, mixed features, family history, postpartum mania; (2) schizophrenia/schizoaffective — primary psychosis course, psychosis without full mood syndrome for substantial periods, negative syndrome trajectory; (3) substance/organic — UDS already negative/TSH normal here, but still consider steroids, occult medical illness, late-life cognitive/organic flags if present. ^[5]

(ii) Acute risk. Elevated completed-suicide risk phenotype; delusional drivers ("deserves to die"), means (stockpiled tablets), need means restriction, appropriate observation, senior review, admission intensity already in play. Assess capacity for treatment decisions; use least-restrictive lawful pathway under local mental health legislation if incapacitous and high risk — do not invent section numbers. Safety plan and family involvement; remove lethal means from home before leave. ^[3][5]

(iii) Pharmacological plan. Combination antidepressant + antipsychotic, not monotherapy. Example aligned with STOP-PD: sertraline start 50 mg orally daily, titrate toward 150–200 mg as tolerated; olanzapine start 5 mg orally at night, titrate toward effective STOP-PD-range doses (commonly up to about 15–20 mg) as tolerated. Monitor weight, glucose, lipids, sedation, EPS/akathisia; ECG if cardiac risk; counsel SSRI adverse effects and early activation/suicidality monitoring. Landmark logic: STOP-PD showed olanzapine+sertraline superior to olanzapine+placebo for remission; meta-analysis supports combination over monotherapy. ^[1][6][5]

(iv) ECT first-line. Choose early ECT if food/fluid refusal, catatonia, uncontainable suicide risk, need for rapid response, prior excellent ECT response, pregnancy risk–benefit favouring ECT, or failed/intolerable combination pharmacotherapy. UK ECT Review Group supports strong efficacy in severe depressive disorders. ^[4][5]

(v) Continuation (STOP-PD II). After remission on sertraline+olanzapine, continuing olanzapine with sertraline reduced relapse versus sertraline+placebo. Discuss duration of antipsychotic, metabolic trade-offs, gradual taper only when stable with close monitoring for psychotic re-emergence; continue antidepressant maintenance and psychosocial care. ^[2]